The Hidden Curriculum : What are our students REALLY learning from us? Tim Ridgway, M.D., FACP Associate Professor of M

1. The Hidden Curriculum: What are our students REALLY learning from us? Tim Ridgway, M.D., FACP Associate Professor of Medicine Dean of Clinical Faculty tim.ridgway@usd.edu

2. Objectives • Define the “hidden curriculum” • Provide examples of the core themes of the hidden curriculum • Make us aware of the prevalence of this entity in our day-to-day lives • Offer possible solutions on dealing with this issue

3. Not all of what is taught during medical training is captured in course catalogs, class syllabi, lecture, notes and handouts…. Indeed, a great deal of what is taught – and most of what is learned – in medical school takes place not within formal course offerings but within medicine’s “hidden curriculum.” Frederick Hafferty (1998)

4. The Formal Curriculum • The stated, intended, formally offered and endorsed curriculum • The “this is what we do” curriculum

5. The Informal Curriculum • An unscripted, predominantly ad hoc, and highly interpersonal form of teaching and learning

6. The Hidden Curriculum • Learning that occurs by means of informal interactions among students, faculty and others • Learning that occurs through organizational, structural, and cultural influences intrinsic to training institutions • This curriculum is buried in the lived experience of learners.

7. The Hidden Curriculum: Defining Concepts • Medicine of culture • Haphazard interactions • Role modeling • Medicine as ideal vs. medicine as reality

8. The Hidden Curriculum: Core Themes • Power and hierarchy • Patient dehumanization • Hidden assessment • Emotional suppression • The limits of medicine

9. The Hidden Curriculum: Core Themes • Emerging accountability • Balance and sacrifice • “Faking it” • Human connection

10. Power and Hierarchy • Use and abuse of power in the hierarchy of medical training and health care • Student-teacher and patient-doctor • Intense pressure to “know their place” • Patients feel pressure to accept physician authority

11. Patient Dehumanization • Patients disrespected, coerced, and dehumanized • Patients stripped of their uniqueness (stories, personality, culture) in service to “objectivity”

12. Hidden Assessment • Feeling “under the microscope” • Feeling judged or evaluated on unnamed criteria • Attributions of success or failure may simply reflect acquiescence or assimilation to the culture of the particular rotation

13. Emotional Suppression • The need to actively suppress emotions in response to the powerful experiences of hospital life • Dissociating oneself from “normal” emotional responses to suffering and death • Wondering about their own lack of emotions

14. The Limits of Medicine • Uncertain role of the doctor in dealing with the nonmedical dimensions of patient well-being • Limits of medicine in addressing the human condition • Inadequate focus on prevention

15. Emerging Accountability • Students’ growing awareness of their duties to their patients and their own learning • Recognition of the need to actively seek out medical education rather than letting it “happen to you”

16. Balance and Sacrifice • Elusive quest for personal/professional balance • Medicine often receives priority over even basic human needs and safety • Role models unable to achieve balance themselves • Culture of times seems to expect sacrifices approaching martyrdom

17. “Faking It” • Need to first “act” like a doctor • Confidence the doctor role will be internalized • Relationship to the white coat

18. Human Connection • Need for authentic human connection for both patient healing and student learning • Connections between peers, students, and teachers, or clinicians and patients

19. Student Lessons from the Hidden Curriculum • Power and hierarchy may serve to maintain and reinforce unprofessional behavior • Student “professionalism” may be equated with subservience within the hierarchy

20. Student Lessons from the Hidden Curriculum • Though suppression of emotion is a pragmatic short-term survival strategy, the long-term consequences are potentially grave. • Multiple studies demonstrate the erosion of empathy over the course of medical training

21. Student Lessons from the Hidden Curriculum • Recent data suggest it may not be the traumatic clinical content of medicine, but rather, student mistreatment and poor role modeling that lead to depression, anxiety, and lack of psychological well-being among medical students

22. Student Lessons from the Hidden Curriculum • The system encourages professionalism and at the same time asks for its evaluation by unprofessional supervisors • Feedback is rarely seen as accurate and is almost never constructive

23. Student Lessons from the Hidden Curriculum • Students learns how to avoid trouble, rather than how to exemplify the virtues of professionalism

24. The Hidden Curriculum: Possible Solutions • Reduce student abuse • Role models • Medical educators should hold themselves accountable for the unprofessional behavior within the medical education system

25. The Hidden Curriculum: Possible Solutions “Faculty, residents, staff, and students alike need to show a personal commitment to the explicit curriculum and address the hidden curriculum openly and proactively.” Brainard and Brislen. Acad Med.2007